Spinal Infections Emerge as Latest Fallout From Exposure to Contaminated Steroid Injections

Spinal infections at the injection site are emerging as the latest concern for patients exposed to steroid injections contaminated with a fungus, Exserohilum rostratum. Image: CDC

About 2 months after the initial cases of fungal meningitis were traced back to injections of a contaminated steroid drug from a New England compounding pharmacy, new patients continue to be identified. The latest wave of patients are presenting with spinal infections, according to Melissa K. Schaefer, MD, of the US Centers for Disease Control and Prevention (CDC).

As of Monday, the CDC has received 510 reports of infection, including 36 deaths, from 19 states among patients exposed to injections of methylprednisone acetate from contaminated lots prepared at the New England Compounding Center (NECC) in Framingham, Mass. Schaefer, who spoke at a CDC briefing for clinicians on Tuesday, noted that two-thirds of the more than 90 cases reported since the beginning of November involve patients with spinal or paraspinal infections, including epidural abscess, phlegmon (inflammation of soft or connective tissue, caused by infection), discitis (infection of the disc space between vertebrae), vertebral osteomyelitis, or arachnoiditis (inflammation of one of the membranes that protects the nerves of the spinal cord) at or near the site of injection. These infections have been seen in both patients with fungal meningitis and those without, according to a CDC alert.

The CDC has also updated its treatment recommendations to encourage physicians to obtain magnetic resonance imaging (MRI) with contrast for patients who have been exposed to the contaminated injections who have new or worsening symptoms. The updated recommendations also advise physicians to have a low threshold for repeating such imaging. Such imaging may help identify local infections, according to the alert.

Anurag N. Malani, MD, an infectious disease specialist at Saint Joseph Mercy Hospital in Ann Arbor, Mich, which has treated more than 150 of the patients with fungal meningitis, noted that because many of the patients were treated with these injections for chronic pain syndromes, it may be “difficult to sort out the truly asymptomatic patients.” Some of his patients who were seemingly asymptomatic reported relief from pain after surgical procedures to debride or drain local infections, noted Malani, who shared his expertise on the call. The CDC is now recommending consultations with a neurosurgeon for patients with local spinal infections, to determine whether such procedures may be beneficial.

Many physicians asking questions during the call expressed frustration about the many uncertainties they face in treating infected patients, including how long and how aggressively to treat.

“When can you say you are out of the woods? I don’t think we have those answers yet,” noted Malani.

Additionally, physicians expressed concern about patients who may have been exposed to other medications from the NECC. The US Food and Drug Administration reported finding microbial contamination in betamethasone and cardioplegia solutions produced at the compounding pharmacy. John Jernigan, MD, of the CDC’s division of healthcare quality promotion, said the CDC has no knowledge of any laboratory-confirmed cases of infection with these other NECC products. Physicians are encouraged to report suspected adverse events associated with these products to their local public health departments and to the FDA’s MedWatch program.

Categories: Infectious Diseases, Patient Safety/Medical Error, Public Health